This document provides information on nursing management of patients with eye disorders. It begins with definitions of visual impairment and functional limitation of the eye. It then discusses management of various causes of blindness such as nutritional deficiencies, refractive errors, infections, and cataracts. The role of the nurse in caring for visually impaired patients is described, including considerations for physical environment, patient interaction, mobility assistance, and providing information. Common ocular drugs are classified and discussed, including anti-inflammatory drugs, mydriatics and cycloplegics, lubricants, and antiglaucoma drugs. Specific drugs are explained in terms of their mechanisms, indications, formulations, dosages, and side effects.

1. MEDICAL SURGICAL NURSING- II
UNIT – II
NURSING MANAGEMENT OF PATIENTS WITH
DISORDERS OF EYE
TOPICS : Role of nurse to care of visually
impaired patients
Drugs in Ophthalmology
.
PRESENTED BY
Mrs. SOUMYA SUBRAMANI, M.Sc.(N)
LECTURER, MSN DEPARTMENT
CON- SRIPMS, COIMBATORE.

2. DEFINITION
The term
functional
"visual impairment" refers
limitation of the eye(s) or
to a
visual
system due to a disorder or disease that
can result in a visual disability or a visual
handicap. For example, macular degeneration
(a disorder) can result in reduced visual
acuity (an impairment in vision.

3. MANAGEMENT:
 The treatment of blindness depends on the cause o
blindness.
 Blindness due to nutritional deficiency: It can be
addressed by dietary changes.
 Visual impairment due to refractive error: It can be
addressed by doing a refraction and providing
appropriate spectacles.

4.  Inflammatory and infectious causes of
blindness can be treated with medication in the
form of drops or pills.
 Most of people are blind due to cataract: In these
patients, cataract surgery would, in most
cases, restore their sight. Usually an
intraocular lens (IOL) is implanted in the eye after
removal of the opaque natural lens.

5.  Consider physical environment.
 Consider interaction.
 Consider mobility assistance for patients who
are familiar with human guide techniques.
 Consider information (e.g., educational material,
instructions, appointments, consents)
ROLE OF NURSE TO CARE OF
VISUALY IMPAIRED PATIENTS:

6. • CONSIDER PHYSICAL ENVIRONMENT.
 Ask about safety concerns, fall risks, and the
ability to find and read signage at each encounter.
 Check the patient area for the location, size and
contrast of signage, and for other obstacles to
safe navigation such as unmarked steps, uneven
flooring and obstructive furniture.
 Consider the impact of environmental lighting,
color contrast

7.  Face and address the patient directly. Make eye
contact and address the patient by name.
 Speak directly to the patient in a normal volume
an natural tone of voice.
 Introduce yourself by name and explain your
function and purpose for care.
CONSIDER INTERACTION:

8. • Explain-compass directions (e.g., “you are facing
waiting room”, or “the door is to your left at nine
feet apart & basic description of a room layout)
• Frequently check on patients while they are in
the room.
• Encourage them to contact staff for needs or
navigating to the washroom.
• Remember that non-verbal cues (e.g.,
gestures) will not work.

9. GUIDE TECHNIQUES:
Ask the patient if and when he or she would like
mobility assistance.
Ask the patient from which side he
or she would prefer to be approached and
guided.
Extend your arm so that it touches the patient’s
arm, allowing him or her to grasp and lightly hold
your arm above the elbow.
(e.g., “you are
PATIENTS WHO ARE FAMILIAR WITH
HUMAN

10.  Do not pull or push the patient, or hold onto his
or her arm. Walk at a relaxed, comfortable pace
and let the patient set the pace.
• The patient will walk a step behind you while
holding your arm Indicate changes in terrain
(e.g., stairs, flooring, transitions ,slopes) by
pausing briefly and describing the changes.

11.  When traveling through a narrow space such as a
doorway or an aisle, put your arm behind you; the
patient will step behind you. The patient’s
hand should slide from above your elbow to right
above your wrist. Return your arm to your side
after you pass through; the patient will step
beside you again and their hand will slide
back up to above your elbow.

12.  When approaching a door, let the patient know if
it opens toward you or away, and if the door
opens from the right or the left. Pass
through the doorway first; the patient will follow.
When seating a patient, place his or her
hand on the back of the chair. The patient
will then seat him or herself. Do not attempt to
push the patient into a chair.

13. Consider information (e.g., educational material,
instructions, appointments, consents:
Remember to maintain patient
confidentiality in
all interactions and protect personal health and
identifiable information (PHI/PII) when reading or
discussing information aloud. Obtain permission
before discussing or disclosing PHI or PII with or
in the presence of designated caregivers or
family members.

14.  Ask the patient how
information
he or she prefers to
(e.g., large printedreceive
material, electronic material, someone reading
important material aloud), and how you can
assist in completing forms or obtaining
a signature, if needed.
Encourage patients to use their own
personal assistive technology in magnifiers,
smart phones and speak text
aloud).

15.  Patients with
magnification
rates.
a visual impairment who use
aids may have slower reading
 They will appreciate text with shorter words and
shorter sentences.
 Consider bulleted or numbered
information that
contains the most vital text whenever possible.

16. Verify that the patient understands the most
the clinic.important information before leaving
Include family members
appropriate.
and caregivers as

17. Drugs in
Ophthalmology
.

18. CONTI..
• Discuss on the ocular drug classification
• Enumerate about anti inflammatory drugs
• Explain about mydriatics and cycloplegics
• Discuss regarding lubricants
• Discuss on antiglaucoma drugs

19. Ocular Routes of Drug Administration
Sr.N
o
Route Special Utility Limitations &
Precautions
1. Topical --Convenient
-- Economical
--Relatively safe
--Compliance
--Corneal & conjunctival
toxicity
--Nasal mucosal toxicity
--Systemic side effects from
nasolacrimal absorption
2. Subconjunctival, -Anterior segment
sub-Tenon’s &
Retrobulbar
injections
infections
-Posterior uveitis
-Cystoid Macular
Edema (CME)
-Local Toxicity
-Globe perforation
-Optic nerve trauma
-Central retinal artery or
vein occlusion
3. Intraocular
Injections
Anterior segment
surgery or infections
-Corneal toxicity
-Relatively short duration of
action
4. Intravitreal Immediate local effect Retinal toxicity

20. Common Ocular Routes of Drug
Administration
• Drug can be delivered toocular tissue as:
• locally:
• eye drop
• ointment
• periocular injection
• intraocular injection
• systemically:
• oral
• intravenous

22.  Anti inflammatory
Mydriatics and Cycloplegics
Lubricants
Anti glaucoma
COMMON OCULAR DRUGS CLASSIFICATION

23. Anti Inflammatory Drugs
Corticosteriods
NSAID
Mast cell stabilizers
Immunosuppresants

24. CORTICOSTEROIDS
• Useful in control of inflammatory and immunological
diseases of eye
• R outes ofadministration
• Topical
• Periocular
• Intravitreal
• Oral
• Intravenous

25. Mechanism of Action
• their antiinflammatory and immunosuppressive acton
• inhibition of lymphocytes proliferation, with a
decrease of the cell-mediated immunity.
• inhibition of the degranulation of neutrophil,
granulocytes, macrophages, mastcells
and basophil granulocytes.
• decrease of vascularpermeability.
• decrease of prostaglandinproduction.

26. Indications
• post surgical inflammation
• allergic conjunctivitis and blepharitis
• vernal conjunctivitis,
• phylectunular keratoconjunctivitis
• disciform and interstitial keratitis
• corneal graft rejection
• scleritis and episcleritis,

27. Indications
• anterior and posterior uveitis
• traumatic inflammation of the eye
• papillitis and retrobulbar neuritis
• sympathetic ophthalmia
• herpes zoster ophthalmicus
• orbital pseudotumor

28. TOPICAL CORTICOSTEROIDS
• available as solution, suspension andointment
• Hydrocortisone0.5-1.5%
• Prednisolone 0.12, 0.25, 1%
• Dexamethasone 0.1%
• Betamethasone 0.1%
• Triamcinolone0.1%
• Fluromethalone0.1%
• Loteprednol0.2%,0.5%
• Difluprednate0.005%

29. RECENT ADVANCES
• DIFLUPREDNATE 0.05%( Diflucor,
Diflupred)
• prednisolone derivative, in emulsion form
exhibits enhanced , strongefficacy and low
side effects.
• indicated in post operative inflammation and
uveitis only qid dosing is required.

30. • OZURDEX® (Allergan)
(dexamethasone intravitreal implant 0.7mg),
• indicated in
• macular edema following retinal vein occlusion.
• noninfectious posterioruveitis.
• Oral prednisolone in a dose of 1-2 mg/kg/day
(or alternate days) is used to treat orbital
inflammations, panuveitis, postoperative

31. • High dose of methylprednisolone i/v are given
in pulses to treat opticneuropathies.

32. NON STEROIDAL ANTIINFLAMMATORY
DRUGS
• Has 3 types ofeffects
Anti-inflammatory
Analgesic
Antipyretic (COX-2)
Inhibits the cyclo oxygenase pathway

33. OCULAR INDICATIONS FOR USE OF
NSAIDs
• preventionof intraoperativemiosis
• reduction of postoperativeinflammation
• preventionand treatmentof cystoid macular edema
• non infectiousuveitis
• scleritis andepiscleritis
• allergic and giant papillaryconjunctivitis
• after refractivesurgery

34. FLURBIPROFEN KETOROLAC DICLOFENAC
Salient features 0.03% solution 0.5% solution
analgesic and
anti-
inflammatory
0.1% solution
potent NSAID
with analgesia
Indication
inhibition of
intraoperative
miosis
ocular itching
due to
seasonal
allergic
conjunctivitis
Foreign body
sensation
and photophobia
iatrogenic
inflammation,
post cataract
surgery pain

35. Dosage
1 drop every 30
minutes, 2 hrs
preoperatively
(total of four
drops)
TDS QID
Side effects
•transient
burning and
stinging
•may cause
increased
bleeding
tendency of
ocular tissues
during
surgery
•transient burning and stinging
•decrease in corneal sensitivity

36. NEWER DRUGS
• Nepafenac 0.1% and Bromfenac 0.09%are topical,
nonsteroidal anti-inflammatory, recently introduced
• Nepafenac is a prodrug, converted by ocular tissue
hydrolases to amfenac, which inhibits the action of
prostaglandin H synthase(cyclooxygenase)
•

37. • patients treated with these drugs were less likely to
have ocular pain and measurable signs of inflammation
(cells and flare) in the early postoperative period as
compared to ketorolac*
• indicated for the treatment of post operative pain and
inflammation, cystoid macular edema.

38. MAST CELL STABILIZERS AND
ANTIHISTAMINES
Humaneyehas about50millionmastcells, which contains
preformedchemicalmediators
Allergic conjunctivitis
IgE mediatedhypersensitivityreaction
Mastcells and basophils
Histamine Leucotrines Chemotacticfactors
stimulatesnerve endingscapillary dilatation
increasedpermeability
painand itching
conjunctival injectionand swelling

39. IMMUNOSUPPRESSANTS
• not used as primarytherapy.
• cases non responding tosteroids or steroids responders
or started having steroid complications.
• avoided in children and pregnant women.
• effect maytake 1-4 weeks todevelop, hence initial
therapywithcorticosteroids is needed.
• Azathioprine, Cyclosporin, Methotrexate Mare commonly
being used.

40. Drug Formulation Dosage Adverse
effects
Special
points
Methotrexat
e
2.5, 5, 7.5
mg
Weekly GI
sympto
ms,
hepatoto
xic
( LFT)
Less
cost,
Well
tolerated
Azathioprin
e
25, 50 mg 1mg/kg Myelosup
pres
sio n
Onset
take 4-
5
weeks

41. Cyclosporin
e
25, 50 mg
0.05%,0.1%
emulsion
5mg/kg/day Nephroto
xic (urea,
creatinine)
Fast
onset of
action
More
efficacious
Dry eye
Mycophenol
ate
mofetil
250, 500 mg 1gm BD Myelosuppr
essio
n
High cost
Leflunomide 10, 20 mg 100mg/day GI
upset,
hepato
toxic
Still under
trial

42. MYDRIATICS AND CYCLOPLEGICS
Mydriatics arethedrugswhichdilate thepupiland cycloplegics are
agents whichcauses paralysis ofciliary muscles.
Mydriatics
Adrenergic agonist Cholinergic antagonists
Adrenaline Phenylephrine Tropicamide

43. PHENYLEPHRINE (2.5%)
• most common sympathomimetic agent used
• acts on alpha1receptors of the dilator pupillae.
• Indication
• pupil dilation
• refraction
• before intraocularsurgeries
• contraindication
• hypersensitive
• narrow angleglaucoma
• cardiac patients
• elderly patients

44. • Sideeffects
• initial stinging andburning.
• systemic side effects include palpitation,
tachycardia, headache, arrythmias
• reflex bradycardia, pulmonary embolism,
myocardial infarction.

45. ADRENALINE
• acts on dilator fibres and directly produces
dilation afterinstillation of four drops of 1:1000
solution.
• may be combined with procaine and atropine to
achieve mydriasis in severe iritis.

46. CYCLOPLEGIC MYDRIATICS
ACTION
• parasympatholytic agents are commonlyused
• blocks the action of cholinergic stimulation
causing paralysis ofaccomodation and pupillary
dilation
Indication
• refraction
• inflamation of uvea
• malignant glaucoma

47. • Adversereaction
• transient stinging and burning, increase in IOP,
allergic lid reaction, hyperemia
• flushing and dryness of skin, blurred vision,
dryness of mouth and nose, anhidrosis, fever,
bladder distention and CNS disturbances
• commonly used agents are atropine sulfate,
homatropine, cyclopentolate, tropicamide.

48. ATRO
PINE
(1%)
HOMAT
ROPIN
E (2%)
TROPIC
AMIDE
(0.5,1%)
CYCLOP
ENTOL
ATE (0.5,1)
Instillation
regime
rice grain
size thrice
a day for 3
days
6-8 drops
10
min apart
2 drops 5
min
apart
2 drops 5
min
apart
Onset 18 hr
after last
instillatio
n
40 min
after 2nd
drop
20 min
after 2nd
drop
30 min
after 2nd
drop
Recovery 10-14 days 3 days 4 hours 2 days

49. Indications refraction
children
<7yrs,
strongest
cycloplegic
acts more
quickly and
shorter
action,
early
recovery
diagnostic
procedures
refraction,
fundus
examination
short acting
Other Uses drug of
choice in
anterior
segment
inflammation,
penalisation
in amblyopia
low
grade
Uveitis
pre and
post
operatively,
provocative
test for
glaucoma
most
commonly
used post
cataract
surgery
Side effects dose related
side
effects
Similar as discussed before

50. TOPICAL HYPEROSMOTIC AGENTS
• these agents are helpful in treatingcorneal edema
of diverse etiology.
• epithelial edema is more responsive as compared to
stromal edema.
• osmotic gradient is created between epithelium and tear
film bythese agents.
• water is then drawn towards themore osmotic
compartment and isthus eliminated fromtheepithelium
and stroma.

51. • commercially availableas
• Topical NaCl solution (2% &5%)
• Topical NaCl ointment (6%gel)
• dosage is 5 to 6 times a day for drops and
2-3 times a day for gels till the desired
response is achieved.
• gel form is more superior in terms of
efficacy and tolerability.

52. OCULAR LUBRICANTS
• available as drops, gels andointments
• indication
• protection andlubrication
• exposure keratitis, decreased corneal sensitivity,
recurrent corneal erosions

54. • Hydrogels are the viscosity enhancing
active ingredients of artificial tears.
•Reduce the risk of bacterial
contamination
• E.g.benzalkonium Chloride, oxychloro
complex

55. • Adverse effects of tearsubstitute
• redness
• stinging and temporary blurring of vision
• hypersensitivity reactions
• Examples
Carboxymethylcellulose
Hydroxyethyl cellulose
Hydroxypropyl cellulose
Hydroxypropylmethyl cellulose

56. OINTMENTS
• major advantage is thatointment is retained longer
than solution
• available as petrolatum, lanolin, mineral oil topical
ointment
Dosage
• bed time ispreferred
• Solution should be instille d prior to
application of ointment
Recentadvances
• Carbopal 980(polyacrylic acid) containing gel is
developed minimises blurring and less dose is
required.

57. ANTIGLAUCOMA DRUGS
• CHOLINERGIC AGENTS
Cholinergic drugs either act directly by stimulating
cholinergic receptors or indirectly by inhibiting the
enzyme cholinesterase.
Topically applied cholinergic agents causes contraction
1) iris sphincter - miosis
2) circular muscles of ciliary body -relaxing
zonular tension &forward lens movement -
accommodation

58. 3) longitudinal muscle of ciliary body-Tension on
scleral spur
• Opening of trabecular
meshwork
• aqueous outflow

59. • PILOCARPINE
• oldest and most widely used
Cholinergic agent, derived from the
plant pilocarpus microphylus.
• Topical solution is available in two salts:
Pilocarpine hydrochloride
Pilocarpine nitrate

60. produces a reduction in IOP that starts after one
hour and lasts for 4-8 hours.
IOPdecrease is 15-20%

61. • CARBACHOL
• It is a synthetic derivative of choline.
longer acting than pilocarpine.
• indications
• intracameral use 0.1% during anterior segment
surgery
• can be used in patients who are allergic to
pilocarpine

62. • reduce IOP 20-30% with little or no effect on pupil size
or.accomodation.
• MECHANISM OF ACTION
decrease aqueous humour production by inhibition of
catecholamine stimulated synthesis of c-AMP

63. • Βeta BLOCKERS
usually first line agent for treating most types of
glaucoma
• excellent IOP lowering efficacy
• long duration ofaction
• few ocular sideeffects
• firstcommercially available β blocker
• for systemic use , waspropanolol
• for topical use was timolol

64. ALPHA ADRENERGICAGONIST
• Directly actingsympathomimetics
• Epinephrine
• Dipivefrin
• Alpha2 adrenergicagonists
• Apraclonidine
• Brimonidine
• Indicatedin
• open angle glaucoma
• to control IOP spikes after laserprocedures
• ocular hypertension

65. • inhibits enzyme carbonic anhydrase present
in pigmented and non pigmented epithelium of
ciliary body
• preventsthe bicarbonate and sodium
influx and decreases aqueous formation
• useful in short termtreatment of acute
glaucoma

66. • onset of action within 1 hour and maximum
effect in 4 hours
• Examples
• DORZOLAMIDE
• BRINZOLAMIDE

67. PROSTAGLADINS
• The PGs derivates primarily lower IOP by enhancing
theuveo-scleral outflow of the eye.
possible mechanism exists that have been studied are
relaxation of the ciliary muscle and remodeling the extra
cellular matrix of the ciliary muscle.
•

68. • first line for open angle glaucoma, ocular
hypertension, exfoliation and pigmentary glaucoma
• less certain indications in angle
closure,neovascular glaucoma.
• contraindicated in allergic patient, pregnancy,
uveitic glaucoma.

69. • Examples
• LATANOPROST
• TRAVOPROST
• BIMATOPROST

70. SYSTEMIC ANTI GLAUCOMA
• Oral
• Acetazolamide
• Glycerine
Intravenous
• Mannitol
Neuroprotectiveagents
• Calcium channel blockers
• Nitric oxide synthaseinhibitors
• Vasodialators
• Antioxidants

71. • ACETAZOLAMIDE
• oral carbonic anhydraseinhibitor
a)Tablet 125mg/250mg, TDS/BD
• onset of action within 1 hr
• Peak at 4hrs
• Duration of action 8-12 hrs
b)Slow release capsule
• GivenOD/BD
• Duration of action upto 24 hrs

72. c)Intravenous
• 500mg vials
• Immediate onset , peak action at 30
minutes
• useful in acute glaucoma, cystoid macular
edema, altitude sickness, epilepsy, respiratory
stimulant

73. • HYPEROSMOTIC AGENTS
• Increase the osmolarity of plasma
• Leads to absorption of water from ocular tissues(
mainly vitreous)
• indication
• acute glaucoma
• secondary glaucoma, preparation of patients before OT
• malignant glaucoma

74. • adverseeffects
• headache, nausea,vomitting
• systemic hypertension
• congestive heart failure and pulmonary
edema
• urinary retention andhyperglycemia

75. • OralGlycerol
• 50%solutionindose of1.5to3ml/kgbody weight
• poorly penetratesintotheeye
diabeticsmayhaveproblemduetocaloric value,
osmoticdiuresis anddehydration
• Mannitol
• 20%concentration
• 1-2gm/kgbodyweightor5-10ml/kgbody weight
• peakaction-within30mins
• durationofaction-upto6hours
• choiceforintravenoustherapy

76. NEUROPROTECTIVEAGENTS
• To protect the optic nerve damage by-
• Block the endogenous substances which may
have damaging effect on ganglion cells.
• Prevent neuronal degeneration and promoting
regeneration.
•

77. • Endogenous substances released during
glaucoma are
• Excitotoxins-glutamate andaspartate
• Elevated intracellularCa++
• Nitric oxide
• Free radicals

78. EXAMPLES OF NEURO PROTECTIVE
AGENTS
• Agents that promote regeneration
• Calciumchannel blockers
• Nitric oxide synthaseinhibitors
• Antioxidants
• Vasodilators